NHPCO: CMS Did Not Account for Full Burden of Implementing HOPE Tool

The U.S. Centers for Medicare & Medicaid Services (CMS) may not have accounted for the financial and administrative burdens associated with its implementation of the Hospice Outcomes and Patient Evaluation (HOPE) Tool.

In comments on the 2025 proposed hospice rule, the National Hospice and Palliative Care Organization (NHPCO) voiced concerns that the agency’s regulatory impact assessment may not have taken all the details into account, including the need for staffing and technology investments.

“Clinical and administrative cost calculations do not align with the reality of the true costs of implementation,” NHPCO indicated in a letter to CMS. “In the proposed rule, CMS significantly underestimated the burden and costs hospices will incur to comply with HOPE requirements. The agency’s estimated cost burden of approximately $185 million across all hospices fails to account for several important factors.”


The tool is slated for an October 2025 implementation, according to the proposed rule. The tool will replace the Hospice Item Set (HIS) quality reporting system. In contrast to the HIS system, which extracts item set data from a patient’s medical record using a standardized mechanism, the HOPE tool will measure aspects of hospice care at different points in the patient’s experience.

For example, among the processes involved in the tool are Symptom Reassessment Visits (SRA). The SRA is an in-person visit expected within two calendar days as a follow-up for any pain or non-pain symptom impact rated as moderate or severe, according to CMS. As many as three of these visits may be necessary during a patient’s time in hospice.

However, NHPCO contends that the agency did not take SRAs into account when determining the potential costs of implementing the tool.


“CMS did not include the [SRA] in the Estimated HOPE Burden Hours Per Year, despite the SRA’s anticipated frequent use and the staffing burden it will place on hospice providers,” NHPCO said in the letter. “The proposed SRA visit, which must be separate from the HOPE Update Visit (HUV), will include additional in-person visits not contemplated in Table 18 of the proposed rule. These visits will require substantial clinical and clerical work.”

This is part of a larger issue in which CMS did not factor in the full scope of staffing investments that providers may need to make in order to comply, including the necessary clinical and clerical work at admission and discharge, according to NHPCO.

The agency also did not take into account the work of non-nursing disciplines in complying with the tool, such as social workers and chaplains, NHPCO indicated.

Implementing the tool will also require updates to electronic medical record (EMR) systems, but those vendors have yet to receive the information they will need to make those changes, including technical specifications for HOPE data collection and submission requirements.

“Software developers and vendors require these technical specifications to inform accurate development of and updates to their systems — otherwise, significant costly and time-consuming changes must be made, which can impair efforts to timely comply with new data collection requirements,” NHPCO said. “It follows then sufficient time will be necessary to enable this development and ensure a seamless transition to HOPE.”

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